Annals for Hospitalists - August 2023
Authors: David A. Fried
Journal: Annals of Internal Medicine (2023)

Web ExclusivesAugust 2023Annals for Hospitalists - August 2023FREEDavid A. Fried, MDDavid A. Fried, MDFrom University of Michigan, Ann Arbor, Michigan (D.A.F.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202308150 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Highlights of Recent Articles From Annals of Internal MedicineComparative Effectiveness and Safety of Generic Versus Brand-Name Fluticasone–Salmeterol to Treat Chronic Obstructive Pulmonary DiseaseAnn Intern Med. 2023;176:1047-1056. Published 8 August 2023. doi:10.7326/M23-0615This propensity score–matched cohort study (n = 10 012 matched pairs) evaluated the effectiveness and safety of brand-name versus generic fluticasone-salmeterol for the treatment of chronic obstructive pulmonary disease. Over the 1-year follow-up, the authors found no difference in time to first moderate to severe chronic obstructive pulmonary disease exacerbation (hazard ratio [HR], 0.97 [95% CI, 0.90 to 1.04]) or hospitalizations for pneumonia (HR, 0.99 [CI, 0.86 to 1.15]). The results were similar when they examined total chronic obstructive pulmonary disease exacerbations and total hospitalizations for pneumonia between groups.Key points for hospitalists include:The U.S. Food and Drug Administration approved the generic fluticasone-salmeterol inhaler after a comparative study that only evaluated asthma patients and used FEV1 outcomes rather than clinical outcomes.This study showed equal clinical effectiveness and safety between the generic and brand-name medications (as measured by time to first moderate to severe exacerbation or hospitalization for pneumonia).Follow-up times were short (88 to 101 days depending on the outcome and drug), but similar between drugs, possibly indicating patient-directed treatment discontinuation.The study did not measure the incidence of mild exacerbations or less severe safety risks, such as outpatient-treated pneumonia and oral thrush.Comparative Effectiveness of Sodium–Glucose Cotransporter-2 Inhibitors for Recurrent Gout Flares and Gout-Primary Emergency Department Visits and Hospitalizations: A General Population Cohort StudyAnn Intern Med. 2023;176:1067-1080. Published 25 July 2023. doi:10.7326/M23-0724This propensity score–matched cohort study compared the incidence of recurrent gout flares after initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2is) compared with dipeptidyl peptidase 4 inhibitors in patients with preexisting gout and type 2 diabetes. Of the 8150 propensity-matched patients, those treated with an SGLT2i had fewer gout flares (rate ratio, 0.66 [CI, 0.57 to 0.75]), including flares requiring an emergency department visit or hospitalization (rate ratio, 0.52 [CI, 0.32 to 0.84]). The relative risk was similar regardless of age, sex, or diuretic use, but a larger decrease in risk was noted in patients with higher baseline gout intensity and those who were not already receiving urate-lowering drugs. The study also noted an increase in genitourinary infections (HR, 2.15 [CI, 1.39 to 3.30]) and a reduction in myocardial infarctions (HR, 0.69 [CI, 0.54 to 0.88]).Key points for hospitalists include:This study shows an association with SGLT2is and a reduction in gout flares, likely due to their known urate-lowering effects. Prior studies have shown a benefit in primary prevention of gout as well.The results included a large, 48% reduction in severe flares requiring an emergency department visit or hospitalization.No increase in paradoxical flares was seen in patients not previously receiving a urate-lowering medication, as is seen with allopurinol.The study did not evaluate uric acid levels, so it is unclear if the reduction of flares in patients receiving both an SGLT2i and a urate-lowering mediation was due to undertreatment before the study rather than a synergistic effect.How Would You Manage This Patient With Clostridioides difficile Infection? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAnn Intern Med. 2023;176:1101-1108. Published 8 August 2023. doi:10.7326/M23-0754In this article, 2 discussants provide their answers to the following questions:1. What is the ideal antibiotic regimen for primary nonsevere Clostridioides difficile infection (CDI)?2. What is the ideal nonsurgical management of fulminant CDI?3. When should bezlotoxumab be offered for prevention of CDI recurrence?Key points for hospitalists include:Guidelines recommend oral vancomycin over oral metronidazole for treatment of nonsevere CDI. Studies show that while oral fidaxomicin is noninferior to oral vancomycin in the treatment of nonsevere CDI, it is superior in preventing recurrent disease. This is likely because fidaxomicin is a more targeted antibiotic and causes less disruption of the intestinal microbiome. Fidaxomicin is more expensive, and cost-effectiveness studies show equivalence between the 2 drugs.Fulminant CDI, defined as the presence of ileus, shock, or megacolon, is difficult to treat due to reduced drug delivery to the colon. Fidaxomicin has not been studied in this population. Combined treatment with oral vancomycin plus intravenous metronidazole is recommended, although data is conflicting regarding the efficacy. Rectal vancomycin should be administered if there is any concern for ileus. Consultation with infectious disease, gastroenterology, and general surgery is also recommended for these patients to discuss use of adjuvant therapies and surgical management.Fecal microbiota transplantation is an option for treatment of fulminant disease, especially when refractory to medical therapy and in patients who are poor surgical candidates. The Infectious Diseases Society of America warns of potential pathogen transmission from transplantation and recommends further randomized controlled trials on the topic.Bezlotoxumab is a monoclonal antibody that binds to C difficile toxin B and has been shown to reduce the risk for CDI recurrence. Guidelines recommend administering it in patients who experience recurrent CDI within 6 months of their last infection and considering administration to patients at elevated risk for recurrence (age >65 years, immunocompromise, history of recurrence >6 months after prior infection, and patients whose first infection is severe). There are no contraindications to this drug, but phase III trials showed a slight increase in congestive heart failure (2.2% vs. 0.9% in the untreated group).Pharmacologic Treatment Initiation Among Medicare Beneficiaries Hospitalized With Alcohol Use DisorderAnn Intern Med. 2023;176:1137-1139. Published 27 June 2023. doi:10.7326/M23-0641In this Brief Research Report, the authors evaluated how often clinicians started treatment with medications for alcohol use disorder (MAUD) during and shortly after hospital admission. The medications included in the analysis were naltrexone, acamprosate, and disulfiram. Patients already receiving MAUD treatment were excluded, as were those with contraindications to more than 1 of the medications. Using Medicare Part D claims data, they found that of 20 401 patients hospitalized for alcohol use disorder, only 206 (0.7%) initiated MAUD treatment within 2 days of discharge, and 364 (1.3%) within 30 days of discharge. Younger patients (aged 18 to 39 years), patients admitted to psychiatric hospitals, psychiatry or addiction medicine consultation during hospitalization, and a primary discharge diagnosis of alcohol use disorder were factors associated with higher odds of MAUD treatment.Key points for hospitalists include:In this study, patients hospitalized for alcohol use disorder rarely initiated MAUD within 30 days of discharge.The study did not measure how often patients were prescribed but did not fill medications nor how often patients declined medication prescription.The study also did not evaluate administration of long-acting naltrexone injections given in the hospital.Only Medicare patients were included, and many patients admitted for alcohol use disorder have other insurance plans or lack insurance altogether.The Latest Highlights From Journal ClubShould patients with acute coronary syndrome and multivessel disease receive immediate or staged complete revascularization?In ACS with multivessel CAD, immediate vs. staged complete revascularization was noninferior for a composite outcome at 1 yAnn Intern Med. 2023;176:JC76. doi:10.7326/J23-0049This randomized controlled trial (n = 1525) included patients with multivessel coronary artery disease and either an ST-segment elevation myocardial infarction or a non–ST-segment elevation myocardial infarction. Immediate revascularization of both the culprit lesion and the other nonculprit lesions was noninferior to staged revascularization for death and vascular events at 1 year (relative risk reduction, 21% [CI, −10 to 44]).Do patients with large vessel anterior circulation strokes benefit from endovascular treatment more than 6 hours after presentation?In ischemic stroke, adding EVT to usual care at 6 to 24 h improved functional status at 90 dAnn Intern Med. 2023;176:JC79. doi:10.7326/J23-0050This randomized controlled trial (n = 535) of proximal occlusion, anterior circulation strokes with preserved collateral flow in the middle cerebral artery showed that when added to usual care within 6 to 24 hours, endovascular treatment led to improved functional outcomes at 90 days (mean modified Rankin score of 3 [interquartile range, 2 to 5] vs. 4 [interquartile range, 2 to 6]), with no difference in mortality.How does transcatheter mitral valve repair compare with medical therapy alone in patients with symptomatic, secondary mitral regurgitation?In HF with secondary mitral regurgitation, transcatheter mitral valve repair reduced HF hospitalizations at 5 yAnn Intern Med. 2023;176:JC77. doi:10.7326/J23-0047This randomized controlled trial (n = 614) of patients with heart failure with reduced ejection fraction and symptomatic secondary mitral regurgitation showed that transcatheter mitral valve repair reduced heart failure admissions (HR, 0.53 [CI, 0.41 to 0.68]) and all-cause mortality (relative risk reduction, 18% [CI, 6 to 29]) at 5 years compared with guideline-directed medical therapy alone.Does bempedoic acid improve cardiovascular outcomes in patients intolerant of statins?In statin-intolerant adults with, or at risk for, CV disease, bempedoic acid reduced MACE at a median 41 moAnn Intern Med. 2023;176:JC75. doi:10.7326/J23-0044This randomized controlled trial (n = 14 016) of patients at high risk for a cardiovascular event who were unable or unwilling to take more than very-low-dose statin therapy showed that oral bempedoic acid reduced major adverse cardiac events compared with placebo (relative risk reduction, 12% [CI, 4 to 20]), with a number needed to treat of 62.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David A. Fried, MDAffiliations: From University of Michigan, Ann Arbor, Michigan (D.A.F.)Disclosures:The author has reported no disclosures of interest. Forms can be viewed at https://rmed.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-1807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics August 2023Volume 176, Issue 8 ePublished: 15 August 2023 Issue Published: August 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.Loading ...